PAST MEDICAL HISTORY (Pediatric ≤ 18 years-old)

Patient: ______Today’s Date: ______Date of Birth: ______Age: _____ Gender (please circle): Male Female Family Doctor (Please include phone # and address):______Who sent you to this office?:______WHY ARE YOU HERE TODAY?: ______

What date did your symptoms start/did the injury occur? ______

PAST MEDICAL HISTORY: Serious Childhood Illnesses (include hospital stays and dates):______Major Accidents/Injuries (include dates): ______Has the patient ever received a blood transfusion?: Yes_____ No____ Birth History: Weeks at Delivery: _____ Delivery(please circle):Vaginal delivery/C-section Reason and # of days hospitalized after birth: ______Age child began walking: ______Current Height: ______Current Weight: ______PAST SURGICAL HISTORY: (include procedure, date and surgeon)______

MEDICATIONS: (Please list name and dose)______

ALLERGIES:______

IMMUNIZATIONS: Up-to-date: _____Yes ____No

FAMILY HISTORY: Father: Age_____ Mother: Age_____ Immediate family members’ disease history: (Scoliosis, childhood hip problems, diabetes, cancer, other)______Has any family member had a major adverse reaction to anesthesia?: Yes_____ No____

SOCIAL HISTORY: School: ______Grade/Year:______Who do you live with? ______Interests/Activities: ______Exercise/Sports/Athletic Participation: ______

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PLEASE CIRCLE ANY PROBLEM LISTED HERE IF YOUR CHILD HAS HAD IT AT ANY TIME:

MUSCULOSKELETAL GENITOURINARY Limb or joint pain Blood in urine -which joint? ______Frequent/painful urination

-how often? ______Kidney/bladder infection

-when did it start? ______Incontinence Joint swelling Difficulty urinating Back pain None of the above:______Please use the diagrams below to indicate the symptoms your child has had recently. Pain with activity GASTROINTESTINAL Use the key to indicate the type of symptoms. Pain at rest Ulcers/Gastritis Walking problems Decreased appetite Key: Pins and needles = 00000 Stabbing pain = ///// In toeing (toes turned in) Abdominal pain Bow legs or knock knees Black bowel movements Burning feeling = xxxxx Deep ache = zzzzz Juvenile rheumatoid arthritis Throw up blood Hepatitis None of the above:______ALLERGIC/IMMUNOLOGIC None of the above:______Allergies to medications HEMATOLOGIC/LYMPHATIC Easy bruising/bleeding Seasonal allergies Nose bleeds Food allergies None of the above:______Previous cancer Previous tumor (benign) CARDIOVASCULAR Bump High Blood Pressure Pain that awakens from sleep Shortness of breath None of the above:______

Rapid/abnormal pulse NEUROLOGICAL Heart Murmur Frequent headaches Leg cramps with exercise Fainting or convulsions Poor Circulation Dizziness or tingling None of the above:______Diffuse muscle weakness CHEST/RESPIRATORY Tingling Chronic cough Loss of bowel/bladder control Asthma None of the above:______Has ever used oxygen PSYCHIATRIC Sees Pulmonary doctor Under psychiatric care Positive TB test Psychiatric hospitalization None of the above:______History of substance abuse EARS, NOSE, MOUTH, THROAT None of the above:______Neck pain/stiffness GYNECOLOGICAL Hearing problems Abnormal/irregular periods Ear infections Age periods started: _____ Sinus problems/sinusitis How many periods per year: ___ None of the above:______Date of last period: ______EYES Pregnant now: Yes/No Vision changes None of the above:______Sensitivity to light SKIN Rash None of the above:______Burns ENDOCRINE None of the above:______Diabetes CONSTITUTIONAL Gout Parent Signature______Fever/Chills Thyroid abnormality MD Reviewing Form: ______Night sweats Osteoporosis (weak bones) Weight loss Date: ______None of the above:______Excess weight gain or los

HIV/Exposure to HIV

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